The Use of Modified Cognitive Therapy to Eliminate or Reduce Depression among Persons with Intellectual Disabilities: A Case Study

    

    

    Figure 1:  SPPRD Frame.
    
    

Because individuals with intellectual disabilities (ID) generally have problems with abstract concepts [17], throughout the process in the SPPRD model abstract concrete and complex concepts are made facile through the use of simple language, drawings, and demonstration. In fact, the SPPRD process is broken down in steps in order to avoid overwhelming the client with an elaborate process: the counselor, for example, helps the client to separate false ideas from reality (S), then put things into perspective (PP), and finally the client retains healthy thinking (R) and discards faulty thinking (D) (hence the acronym SPPRD).

Separate

To separate the client’s false beliefs about him/herself from reality (who the client is), the counselors externalize the false beliefs by attributing them to environmental or other external sources [16]. To facilitate understanding, the counselor writes the negative beliefs and positive characteristics on a piece of paper and/or draws pictures of them [1]. Pointing to the drawings, the counselor can signal that it is not the person who is the problem, but rather the external factors. For example, the counselor can say, "This represents who you are" (pointing to a piece of paper with the client’s positive attributes), and "your unsuccessful outcome is the result of ineffective teaching" (pointing to a piece of paper with negative beliefs). This contrast has the potential to counter the client’s false beliefs.

Putting things into perspective

Putting things into perspective (through teaching) reinforces the separation of false beliefs from positive attributes, which was previously dealt with in the first step. Furthermore, it helps persons with ID understand that past failures are reflective of society’s limitations. Separating false beliefs from reality (in the previous step) does not necessarily mean abandoning past failed experiences, which for persons with depression, are stable and universal (Kurtovic, 2012). So, the counselor puts things into perspective through educational intervention (based on the client’s level of understanding) by clarifying that the client’s past failures do not portend failing in current or future tasks, and that their failure in a specific task does not mean failure in other tasks. Counselors can also use McFarlane and Lynggard’s (2009) externalization strategy to educate clients about their failures [16]. For example, the counselors can explain that the client’s past failures are due to discrimination and ineffective methods for teaching persons with ID - not the client’s inabilities or low intelligence levels. This SPPRD step helps clients recant and revise previously held negative beliefs.

Retain and Discard

Separating false beliefs from reality and understanding depression-related issues can lessen or contradict false beliefs, but these thoughts can persist and become recipes for depression if left hovering around. Unlike other CT interventions, SPPRD does more than merely assist clients in disputing negative thoughts; it also helps clients to discard them. The clients’ positive characteristics are retained and used to replace negative thoughts.

Since this abstract process can be difficult for a person with ID, demonstration can be used to concretize the process: the counselor encourages the client to write positive and negative views about him/ herself, with the counselor’s help if necessary [16]. Then, the counselor hands the piece of paper with the positives attributes to the client (as he reminds the client the positive attributes written on the piece of paper are reflective of him/her) and encourages the client to embrace the positive attributes verbally (e.g., "I am intelligent, I am smart"). Similarly, the counselor gives the piece of paper with the negative beliefs to the client (as he reminds him/her the negative statements on them reflect external factors) and encourages him/her to disown the negative beliefs written on the paper by putting the paper in the trash while verbally stating "the beliefs written on this paper do not represent me."

Since the aim is for the client to overcome negative thought patterns in real life situations, in SPRRD (as in CT in general) follow up sessions to discuss the client’s use of knowledge gained in the session (in dealing with challenging negative thoughts in daily life) are crucial. The counselor and the client can discuss strategies to remind the client about his positive attributes and other knowledge gained in the sessions. Direct care workers, guardians, and others can be invaluable; they can support the client in utilizing SPPRD-related strategies in daily life activities.

Method

Instrument

The Patient Health Questionnaire depression scale (PHQ - 9) was used in this study. The PHQ - 9 is a depression detection instrument based on the DSM-1V criteria for the diagnosis of depression [18]. It is reliable and valid across many disability groups, including persons with limited literacy education. It measures depression symptoms’ severity. It takes 4 -6 minutes to complete, is easy to administer and score, and can be used both in clinical and research settings [19]. It is appropriate for those with cognitive/intellectual disabilities (Chan, personal communication, 6/15/2013; [20]) and Latinos [21]. In relation to monitoring treatment outcomes of depression, it has shown success, making it an appropriate match for our case study on depression [19]. With the PHQ - 9, patients rate their frequency of depression from "0" (not at all) to "3" (nearly every day). It consists of nine questions that yield four depression scores: 5, mild, 10, moderate, 15, severe, and 20, very severe [18].

Our rational for choosing the PHQ - 9 as opposed to the Zung depression scale makes sense because the PHQ - 9 is short and easy to understand, has shown success in research in general and in intervention studies in particular and is appropriate for persons with moderate cognitive abilities and for Hispanics in general [21].

Procedure

The client has moderate intellectual disability and depression. The SPPRD frame was used to correct the participant’s faulty thinking. This was accomplished by using "narrative" or "life story," in which the participant told his story and by doing so revealed positive attributes about himself. These attributes were then used to counter his false thoughts. As the participant told his story, he was helped to separate false from real thoughts (S), put things into perspectives (PP), and finally retain his positive attributes (R) and discard his faulty beliefs (D) (as explained in the introduction).

The participant attended five weekly sessions (see below for an example of a session). Each session started with an assessment followed by the intervention, except for week 5. On Week 5, the intervention was not performed. The participant’s depression level was assessed with the PHQ-9 depression scale every week. The counselor and the participant discussed the result to make sure it represented how the he was feeling both during the week and at the present moment. The participant was also assessed regarding other domains (QOL and daily activities, and effect of depression with family and others through verbal discussion).

Example of a session

The participant believed his depression was a result of his unsuccessful effort to gain employment and his academic challenges, such as taking notes and exams, which he attributed to his intelligence and agility inabilities. He used the word "slow" to describe his inabilities. For example, he noted, "I am slow in school, I am slow in running, and I am slow in taking exam."

To deal with these thoughts, the counselor used the SPPRD model - separate false beliefs from reality, put things into perspective, retain his positive attributes, and discard his negative thoughts.

Separate false from reality (S): The counselor first encouraged the participant to talk about instances of positive successes. To help separate the participant’s thoughts (e.g., I am slow in school) from reality, the counselor reiterated the positive aspects of the participant gathered from his life story (he had told in the beginning) and used them to differentiate the participant from his negative beliefs. For example, the counselor explained that the participant’s faulty thoughts and his positive attributes are different and wrote them on two different sheets of papers. Pointing to the paper with the negative thoughts, the counselor noted, "this is not you" and to the paper with the participant’s positive attributes, "this is you. The person who was accepted into college and is keeping up his grades is smart. You are in college and passing your classes - this is you, a smart student" (the participant smiled and shook his head).

Further, the counselor used the participant’s positive story to connect to the present and future. For example, the counselor noted, "You won an award, and that was a success and this means you are intelligent (present); you can use your intelligence to do well in school and work (future).

In addition, the counselor also externalized the problem (negative thoughts) to potential external factors, such as ineffective accommodations and teaching methods for persons with disabilities.

Put these things in perspective (P): After separating the participant from the problem, the counselor used an educational strategy to "put things into perspective." For example, the counselor clarified that failure is not universal and that failure in one situation does not mean a lack of success in other or future tasks. Specifically, the counselor pointed out that inefficient track runners or examinees are not necessarily inefficient employees or students. The counselor used the Rain Man movie (the participant had watched it) as an example. The client nodded his head, agreeing with the counselor’s view point.

Furthermore, the counselor emphasized environmental factors (discrimination) and inappropriate teaching methods as potential causes of unemployment and unsuccessful educational outcomes for persons with disabilities, respectively, while maximizing the client’s ability and intelligence.

Anticipating this educational step would be complex for the participant, the counselor provided information bit by bit, slowed the pace, and used language suited for the participant’s level. Also, the counselor expressed things in different ways and repeated them to reinforce retention (as noted by Zam, et al, 2012).

The counselor also repeated part of the previous step strategy - for example, the counselor differentiated the participant’s false beliefs from reality and used the participant’s positive attributes to counter his negative view.

Even after successful separation of false thoughts from reality and understanding that failure is not necessarily related to a person’s inability, discarding negative thoughts and retaining positive attributes to replace negative thoughts are crucial to avoiding recidivism of negative beliefs.

Retaining healthy thinking (R) and discarding faulty thinking (D)

Thirdly, the counselor assisted the participant with retaining positive views and discarding negative ones (RD) through demonstration. For example, after the client had written positive and negative views about himself on different sheets of paper (as requested by the counselor), the counselor handed the paper with the positives to the client(as he was reminded that the notes on the paper were his attributes). Similarly, the counselor gave the paper with the negative views to the client and encouraged him to put it in the garbage and renounce the views on it, while verbally reminding himself that the notes did not represent his character. The participant denounced the negative views by indicating, "These notes on the paper are not me." He also embraced the positive views by noting, "I am intelligent, I am smart."

Results

The participant’s level of depression dropped from 10 to 3, based on the PHQ-9 depression scale. Specifically, it dropped from ten (10) points on day one, to five points (5) on week two, to four (4) on week 3 and week 4 (the depression score did not drop from week three to week four), and three (3) on week 5, indicating a drop from moderate to mild (for one week) to minimum (for three weeks).

For the verbal assessments immediately after each intervention, the participant noted his depression was better (low) than his depression level before the day’s intervention (the participant was asked to compare his current depression to his depression scored measure before the intervention). There was no intervention the fifth week and so he was not verbally assessed regarding his depression after the intervention. About a month later, the agency staffs stated the client was not showing signs of depression or complaining about his relationship problems.

The client was also assessed regarding other domains (QOL and daily activities, and effect of depression with family and others through verbal discussion). Compared to the first session, the participant indicated positive results (i.e., improvements of his QOL and relationship with others), except his relationship with his friend on the fourth week. However, his relation problem with his friend was positive on week five (Table 1).

  

    

    
PHQ-9 
      
Measure of Depression in 
      
Week 1 
    
PHQ-9 
      
Measure of Depression in 
      
Week 2 
    
PHQ-9 
      
Measure of Depression in 
      
Week 3 
    
PHQ-9 
      
Measure of Depression in 
      
Week 4 
    
PHQ-9 
      
Measure of Depression in 
      
Week 5 
    
Qualitative 
      
Measure 
      
End of Week 5 
  
  

    
USE of SPPRD Intervention 
    
Ten (10)
    
Five (5)
    
Four ( 4)
    
Four ( 4)
    
Three (3)
    
1. Improved QOL    and 
      
2. Improved    Relationship with others 
  

Table 1:  Depression scale.